Provider Demographics
NPI:1306993878
Name:SMITH, BRIAN ROBERT (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:HANA
Mailing Address - State:HI
Mailing Address - Zip Code:96713-0695
Mailing Address - Country:US
Mailing Address - Phone:808-248-8511
Mailing Address - Fax:
Practice Address - Street 1:4216 HANA HWY
Practice Address - Street 2:
Practice Address - City:HANA
Practice Address - State:HI
Practice Address - Zip Code:96713
Practice Address - Country:US
Practice Address - Phone:808-248-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC-804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI51716Medicare ID - Type Unspecified
HI217398Medicare UPIN
HI106565Medicare UPIN